Nabhan et al.

BMC Health Services Research 2012, 12:128

http://www.biomedcentral.com/1472-6963/12/128

RESEARCH ARTICLE Open Access

What is preventable harm in healthcare? A

systematic review of definitions
Mohammed Nabhan1,2, Tarig Elraiyah2, Daniel R Brown3, James Dilling8, Annie LeBlanc1,2,4, Victor M Montori2,4,
Timothy Morgenthaler5, James Naessens4, Larry Prokop6, Veronique Roger1, Stephen Swensen7,
Rodney L Thompson8 and M Hassan Murad1,2,4,9*

Abstract
Background: Mitigating or reducing the risk of harm associated with the delivery of healthcare is a policy priority.
While the risk of harm can be reduced in some instances (i.e. preventable), what constitutes preventable harm
remains unclear. A standardized and clear definition of preventable harm is the first step towards safer and more
efficient healthcare delivery system. We aimed to summarize the definitions of preventable harm and its
conceptualization in healthcare.
Methods: We conducted a comprehensive electronic search of relevant databases from January 2001 to June 2011
for publications that reported a definition of preventable harm. Only English language publications were included.
Definitions were coded for common concepts and themes. We included any study type, both original studies and
reviews. Two reviewers screened the references for eligibility and 28% (127/460) were finally included. Data
collected from studies included study type, description of the study population and setting, and data
corresponding to the outcome of interest. Three reviewers extracted the data. The level of agreement between the
reviewers was calculated.
Results: One hundred and twenty seven studies were eligible. The three most prevalent preventable harms in the
included studies were: medication adverse events (33/127 studies, 26%), central line infections (7/127, 6%) and
venous thromboembolism (5/127, 4%). Seven themes or definitions for preventable harm were encountered. The
top three were: presence of an identifiable modifiable cause (58/132 definitions, 44%), reasonable adaptation to a
process will prevent future recurrence (30/132, 23%), adherence to guidelines (22/132, 16%). Data on the validity or
operational characteristic (e.g., accuracy, reproducibility) of definitions were limited.
Conclusions: There is limited empirical evidence of the validity and reliability of the available definitions of
preventable harm, such that no single one is supported by high quality evidence. The most common definition is
“presence of an identifiable, modifiable cause of harm”.
Keywords: Preventable harm, Systematic review, Healthcare delivery, Safety

Background overall quality of care. Although much is likely prevent-

As part of the Hippocratic Oath, “Primum non nocere”,
the Latin phrase that means "First, do no harm" is a
basis for ethics taught in medical school. Preventing
harms associated with the delivery of healthcare is para-
mount to improve patient safety, a key component of
* Correspondence: murad.mohammad@mayo.edu
1
Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN,
USA
2
Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
Full list of author information is available at the end of the article
able, some harm may be inevitable. For example, post-
operative bleeding may occur and be harmful despite
impeccable surgical technique. Much current discussion
on harm events focuses on hospital acquired conditions
(HAC) including the group historically known as “never
events”. The term "Never Event" was first introduced in
2001 by Ken Kizer, MD, former CEO of the National
Quality Forum (NQF) [1], in reference to particularly
shocking medical errors (such as wrong-site surgery)
that should never occur. In the UK, a framework has

© 2012 Nabhan et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
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reproduction in any medium, provided the original work is properly cited.
Nabhan et al. BMC Health Services Research 2012, 12:128
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been developed for Never Events by the National Patient
Safety Agency including a core list of such events
(updated regularly) and implementation tools for practi-
tioners. This highlights the international interest in pro-
moting patient safety and reducing harms associated
with healthcare delivery [2]. Over time, the NQF list,
which is publically reported in some states (e.g. Minne-
sota) [3], has been expanded to signify adverse events
that are unambiguous (clearly identifiable and measur-
able), serious (resulting in death or significant disability),
and usually preventable [4]. So even in the context of
the NQF “Never Events”, there is acknowledgment that
they are not always preventable.
While a goal of zero harm is desirable, this may not al-
ways be feasible. Many practicing clinicians are dismayed
by general statements about eliminating all harm, but
may be more willing to engage in discussions about sub-
stantially reducing the risk of or eliminating preventable
harm [5]. Therefore, developing a better understanding
of the nature of preventable harm could lead to unam-
biguous communication and superior stakeholder buy-
in. Further, once preventable harm is clearly defined and
standardized throughout the healthcare system, policy
makers can set up necessary plans that would deal with
this pressing issue in a more efficient and reliable
fashion.
The scholarly activities in this field include a system-
atic review conducted by Ferner and Aronson to evalu-
ate the published approaches to assess preventability in
drug related adverse effects [6]. They concluded that the
existing evidence is limited and suggested an approach
based on analysis of the mechanisms of adverse reac-
tions and their clinical features. However, this systematic
review did not consider other types of harm and did not
seek providing a definition of preventable harm. More
recently, similar findings were reported by Hakkarainen
et al. They concluded that new instruments for assessing
the preventability of adverse drug events need to be
developed, or the existing ones be further studied, for a
more accurate and precise measure of preventability [7].
Hayward and Hofer reviewed 111 active-care patient
deaths and estimated that almost a quarter of them were
at least possibly preventable by optimal care [8]. This
study did not consider harm other than death and did
not seek to provide a definition of preventable harm.
Therefore, the aim of this systematic review is to
summarize the definitions of preventable harm used in
the last decade in the published peer reviewed literature
and to assess its conceptualization in healthcare.
Methods
Aim
This systematic review aims at surveying the medical lit-
erature for existing and emerging definitions of
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preventable harm. We focused on the last decade to
evaluate contemporary definitions.
Data sources and searches
We conducted a comprehensive electronic search of
relevant databases (Ovid Medline In-Process & Other
Non-Indexed Citations, Ovid MEDLINE, and Ovid
EMBASE) from January 2001 to June 2011 for publica-
tions that reported a definition of preventable harm. The
search strategy was designed and conducted by an
experienced reference librarian (LJP) with input from
the study’s principal investigator (MHM). Controlled vo-
cabulary supplemented with keywords was used to
search for the topic preventable patient harm. The
detailed strategy is available in Additional file 1. In
addition, we reviewed the reference sections of eligible
studies and available reviews and requested potentially
eligible studies from content experts.
Study selection
Eligible publications were articles that provided 1) a sin-
gle or multiple definitions of harms associated with
health care delivery and 2) defined the preventability of
those harms. We included all kinds of harm: specific
harm such as drug related adverse events, as well as
more general type of harm. We included articles of any
type including primary and review studies, including edi-
torials and commentaries as we were interested in evalu-
ating all the existing definitions of multiple stakeholders
and how they view preventable harm (including
researchers, policy makers and opinion leaders). More-
over, we anticipated that definitions in interventional
studies would have been assumed and not necessarily
validated; thus, having similar face value as definitions in
opinion piece publications. We excluded publications in
non-English language.
Data extraction and quality assessment
Two of the study’s authors (MN, TE) screened all
abstracts and titles. Upon retrieval of candidate studies,
two reviewers (MN, MHM) examined the full text publi-
cations and determined study eligibility. The level of
agreement between the reviewers on the assignment of a
definition theme for preventable harm in each of the
studies was estimated using Cohen’s kappa statistic – a
measure of inter-rater agreement. Agreement was
described as a binary outcome in a 2x2 table (yes, agreed
vs. no, did not agree) and kappa was estimated as the
ratio of (observed agreement – agreement expected by
chance) to (1- agreement expected by chance). Disagree-
ments were resolved by discussion and consensus of the
review team.
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Data synthesis and analysis
The two reviewers, MN and MHM, collected and
synthesized the data. Extracted data included type of
study, description of the study population and setting,
and data corresponding to the outcome of interest (type
and severity of harm, and definition of preventability).
Reviewers categorized the definitions of preventability
encountered in each article into domains (themes).
Reviewers developed the classification terms of the
domains using a saturation approach (new definitions
are added to the list of categories until no new themes
were identified). The severity of harm was extracted as
reported/classified in the included studies (i.e., using
study authors’ designation of severity as a requirement
for inclusion of harm in their study). No classification of
the severity of harm was feasible.
We also extracted data on the operational performance
of the definitions of preventability reported in the
included studies (i.e., feasibility of using the definition and
assigning a level of preventability, measures of agreement
such as kappa statistic among those who assigned a pre-
ventability level, any attempts to validate the definition
and whether the definition had a reference or citation).
We classified agreement based on kappa reported in the
studies as poor, fair to moderate, or substantial [8].
Results
The literature search yielded 460 references; of which
127 were finally included. Study selection process is
depicted in Figure 1. The characteristics and bibliog-
raphy of included studies are described in Additional file
2: Table S1. Cohen’s Kappa statistic among the system-
atic review team averaged 0.86. The definitions were
described in observational studies (45/129, 35%), expert
Yield of search and bibliography
cross reference
n=460
Excluded 116, non-relevant title\abstract
Studies reviewed in full text
n=344
Excluded 217, no definition of preventable harm
Potentially appropriate studies to be
included in the systematic review
n=127
Figure 1 Study selection process.
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opinion publications (non-original studies, opinion piece
and commentaries) (41/129, 32%), cross-sectional stud-
ies (27/129, 21%), systematic reviews (9/129, 7%), con-
sensus statements (4/129, 3%), and case reports, case–
control studies and randomized trials (3/129, 2%). Sev-
eral studies reported the implementation of different
interventions aimed at the reduction of patient harm
with varying success. These data about interventions
were sparse and not analyzed.
Type of harm
The three most prevalent preventable harms cited in the
included studies were medication adverse events 26%
(33/127 studies), central line infections 6% (7/127) and
hospital-stay related venous thromboembolism 4% (5/
127) where medication adverse events are defined as
errors in prescribing, delivering or monitoring the effects
of the drug, which is different from regular side effects.
Most of the studies 76% (96/127) were conducted in in-
patient setting. Additional file 3: Table S2 shows the
number of articles that used each definition of harm and
the type of harm associated with it.
Definitions of preventable harm
Each retrieved publication provided a single definition
with the exception of two [5,9] which respectively pro-
vided five and two definitions. A hundred and thirty two
definitions were analyzed. These fell into seven themes
for preventable harm (Figure 2):
1) Presence of an identifiable modifiable cause: 44%
(58/132)
2) Reasonable adaptation to a process will prevent
future recurrence: 23% (30/132)
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Frequency of definitions
Figure 2 Frequency of definitions of preventable harm and the level of agreement reported in the studies that used multiple
evaluators to assign a preventability level.
3) Lack of adherence to guidelines implies
preventability: 16% (22/132)
4) Morbidity adjusted risk estimates using observed
over expected models to account for preventable vs.
inevitable harm (models typically adjust for severity
of illnesses, patient demographics, comorbid
conditions, and diagnoses): 7% (9/132)
5) All harm is preventable: 6% (8/132),
6) Comparison with another cohort shows different
incidence: 2% (3/132)
7) Historical comparison– events with declining
incidence over time are considered to be preventable
in current practice: 2% (2/132)
There was an increase in the number of publications
in the second half of the last decade. This was accounted
for by the increased use of mainly two definitions: pres-
ence of an identifiable modifiable cause and adherence
to guidelines (Figure 3).
Most of these definitions were author derived (67/127,
53%) and did not cite a specific source of the definition
of preventable harm. In the remaining articles, three
publications were cited the most as a source for the def-
inition of preventability [10–12]. Notably, the definition
used in these three articles was “the presence of an iden-
tifiable modifiable cause”.
Severity of harm
Fifteen of the included studies provided a description of
the severity of harm reported. It was mostly described
when the harm was an adverse drug event (in 7 studies).
Three of the studies considered only severe harm and 12
included all levels of harm. Fifty percent of the studies
that provided specific severity classification used the
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Agreement
Measure
“Presence of an identifiable modifiable cause” as a defin-
ition. Unfortunately, data were sparse and insufficient to
analyze the severity of harm and its effect on
preventability.
Validity and operational characteristics
We found no data on the validity or feasibility of using
the various definitions. Several studies however, reported
a measure of agreement (often reported as a kappa stat-
istic) among the researchers of the study. This measure
described their agreement on the assignment of prevent-
ability of the harms reported in their study (Figure 2).
Across all studies and all definitions, kappa statistic ran-
ged from 0.23 to 0.95. Mean kappa statistic reported in
the studies for each definition domain was: 0.82 (reason-
able adaptation to a process will prevent future recur-
rence), 0.76 (morbidity adjusted risk estimate), 0.64
(presence of an identifiable modifiable cause), 0.62 (his-
torical comparison) and 0.54 (adherence to guidelines).
No agreement data was available for the remaining
definitions.
Discussion
Main findings
Reducing patient harm has been identified as one of the
main areas needed to improve both outcomes and costs
of healthcare. The US Department of Health and
Human Services, in forming the Partnership with
Patients initiative has specifically targeted a reduction in
preventable harm by 40% as one of its two key goals
[13]. The American Food and Drug Administration’s
Safe Use Initiative has targeted to “measurably reduce
preventable harm from medications [14].” Other inter-
national agencies and organizations are also highly
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20
15
10
5
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Figure 3 Year of publication.
interested in this area. To measure our progress toward
these goals, we need a validated metric that clearly
incorporates the definition of a medical harm event and
the level of preventability of such an event. Consulting
the literature using a structured search strategy, we have
identified seven key “themes” in extant definitions of
“preventable harm”, with the most common being a) a
harm with an identifiable and modifiable cause, b) “harm
where a reasonable adaptation to a process will prevent
future recurrence”, and c) “harm where an existing
guideline has not been adhered to”. Our review revealed
that, for the most part, these definitions are locally
derived (67/127, 53%) and lack external validation. Inter-
estingly, some of the other definitions such as all harm
is preventable, were less commonly used. This implies
that the definition of a Never Event is somewhat vague,
dynamic and not standardized. Indeed, the 25 Never
Events defined by the UK National Patient Safety Agency
have numerous exceptions and modifications that high-
light this challenge. We will discuss the three most com-
mon definition domains encountered in more detail and
provide suggestions on what we think is a suitable ap-
proach to advance this critical area of health care
delivery.
1) We have shown that the most common theme used
to define preventability was “a harm with an
identifiable and modifiable cause.” In studies using
this definition, the researchers apparently had
confidence that they could identify a specific “cause”
and conclude that it was preventable because there
was a single correct and achievable management
choice (e.g., one medication was ordered but
another delivered, medication error), or because the
raters determined that most practitioners would
have followed a different (more desirable)
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Presence of an identifiable modifiable cause
Reasonable adaptation to a process will prevent future recurrence
Adherence to guidelines
Morbidity adjusted risk estimate
All harm is preventable
Comparison with another cohort
Historical comparison
Total
management plan. Such criteria may risk becoming
circular to some extent; a preventable cause is
preventable. At a minimum, to minimize bias and
inaccuracy, one would hope for assurance of the
reproducibility and agreement of such judgments
between observers (typically measured with a
chance-adjusted measure such as the kappa
statistic). Other characteristics such as criterion and
convergent validity of the measure will be desirable
but hard to achieve.
The major threat to the validity of such a
judgment is hindsight bias. To avoid this situation
and preserve the validity of this definition, the
direct cause of harm should be definitely
detectable before it has an opportunity to cause
harm (e.g., administering the wrong drug to the
patient). Some studies attempted to prevent
hindsight bias (e.g., Hayward et al [7]. gave
instructions to reviewers of harm cases to not
consider certain aspect of the patient history and
process of care); however, this is always
challenging in observational studies. This
definition and protection from hindsight bias
requires an all-or-nothing cause-and-effect
relationship, the kind associated with large
effects. For causes weakly associated with harm
(e.g., low quality handoffs among trainees),
studies with rigorous protection against bias (e.g.,
randomized trials) would be needed to establish
that harm is indeed preventable by affecting a
specific causal pathway (e.g., improved
communication tools to enhance resident
handoff ). One challenge in using this definition is
that it does not always include “near misses”.
These are cases in which harm did not occur but
was likely to take place.
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Medication events were the most common type
of harm described with this theme (“a harm with
an identifiable and modifiable cause”) (20 out of
58 articles), and for those, only 7/20 had
agreement measures reported, with the median
kappa = 0.69 (range 0.49-0.93); consistent with
good agreement. We have no data regarding the
agreement from the other 13 studies examining
medications that embraced this definition for
preventable harm. One might suspect it would be
harder to assign preventability to non-medication
events where the process of care is more complex
and less explicitly defined than it would be for
adverse medication events, where pharmaceutical
prescription, transcription, distribution, and
ultimately administration is typically well worked
out. However, there were measures of agreement
in 8/38 studies addressing more complex causal
chains associated with harm under this definition,
with a median kappa = 0.68 (0.23-0.81). Thus,
using this definition, the processes used and
developed locally lead to good agreement in
determination of preventable harm when
measured. However, it is important to recognize
here that the included studies judged
preventability a posteriori; thus, hindsight bias
has clearly inflated the observed agreement.
There were no assessments of criterion or
convergent validity.
2) In some ways, the second most common definition
(“harm where a reasonable adaptation to a process
of care will prevent recurrence of harm”) is an
extension of the most common definition reviewed
above. Using this definition, the root cause(s) of
harm were identified and the reviewer(s) judged that
modifying the processes of care could prevent this
type of cause from repeating itself under the same or
similar circumstances. Here, evaluation of drug
events made up only 8/30 such studies, with the
remainder examining a wide variety of medical
events. Only one evaluated agreement between
observers (kappa = 0.95) [15]. For non-medication
event studies using this definition, only two studies
measured agreement with Cohen’s kappa ranging
from 0.68 to 0.83, consistent with moderate to
substantial agreement. In 20, there was no
assessment of agreement, and again, there were no
external assessment of validity or control for
hindsight bias. Perhaps most clearly here, this
definition would require rigorous designs to
establish with confidence that a certain modification
could certainly lead to harm avoidance.
3) The third most common definition of preventable
harm was “harm where an existing guideline has not
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been adhered to”. This definition introduces slightly
different criteria to the assessment of whether or not
an event is determined to be preventable from the
prior ones. It is assumed that the existing guideline
applies to the given situation, and that if the
guideline was followed correctly, any harm
associated with care should be considered to be not
preventable. Conversely, any harm occurring in a
situation in which the guideline was not followed is
credited as “preventable” even if there is the
possibility for disconnection between cause and
effect. It is a measure of the reliability of care
associated with situations that can result in harm.
Twenty studies used this criterion, and 4 reported
agreement with median kappa = 0.57 (0.40-.99).
Event types were mostly related to venous
thromboembolism (4), healthcare associated
infections (5), or adverse drug events (2); all events
for which there are generally well-established care
guidelines. It is not clear why there appeared to be
less agreement (lower kappa) in these situations
compared with other definition types. However, in
several cases, the care guidelines used were
externally developed (e.g., the ACCP guidelines for
venous thromboembolism prophylaxis) [16], so this
data might reflect some measure of criterion
validity. Other definitions were not used as often
and most did not have assessments of agreement. It
is also important to recognize that a significant
proportion of guidelines either have poor quality and
lack rigor or are based on low quality evidence [17].
The quality of evidence
As acknowledged in the reviewed literature, most of
measures of preventable harm were not created for com-
parison purposes; they were locally created to foster en-
gagement of the local caregivers in efforts to improve
patient safety. Measures based on administrative data,
though less “subjective” and hence more applicable for
cross-platform comparison, suffer from their own valid-
ity problems. First, such measures rely on administrative
data, so that documentation and coding can improve
“performance measures” more readily than actually bona
fide improvement in safety and reliability. Secondly, ad-
ministrative indices include adverse events that, by a rea-
sonable standard with today’s science and technology,
are not truly preventable. For instance, the skin organ
system, like the liver organ system, at some point in the
aging and critically ill patient may fail. Even with the
best bedding materials, operative tables and conscien-
tious nursing skills and diligent evidence-based care,
some pressure ulcers are likely inevitable in contempor-
ary practice. Failure to distinguish such events from
those that may actually be preventable affects the
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credibility of the measure with clinicians, who may then
dismiss other aspects of the measures.
An ideal metric would have characteristics of being ac-
curate, valid, reproducible, and would have a high poten-
tial to engage caregivers in improvement work. As any
other causal inference, the confidence in an estimate of
a causal association between a modifiable event and the
risk of harm is related to the validity of the evidence
supporting such association. As in therapeutic associa-
tions, randomized trials are better suited to establish the
preventable harm association when the risk of harm is
moderate to high and the association small (when mul-
tiple contributing factors exist and noise and bias are of
similar size as the signal or effect being detected). Large
effects in a context where confounders are not problem-
atic, compelling dose–response evidence, and protec-
tions against ascertainment bias of exposure and harm
and selection bias further the quality of this evidence.
All-or-nothing associations are associated with large and
idiosyncratic harms and their link is obvious (e.g., wrong
side surgery). However, the chain of events that led to
such an event may be complex and convoluted and solu-
tions to reduce the chance that this harmful process will
repeat will likely require empirical evidence of efficacy.
Given the known limitations of standards of care and
guideline statements, their efficacy in preventing harm
should also be empirically tested. Therefore, the overall
quality of the current evidence in the field (strength of
inference) remains quite limited.
Principles for forging ahead
Preventable harm, therefore, appears to be best defined
by three criteria: (a) harm with an incidence that can be
reduced by virtue of detecting and intervening or pre-
venting a causal event or chain of events (an error, an
error-prone process, deviation from best practice), (b)
the causal event or chain of events by their nature can
be detected before the harm takes place, (c) there is evi-
dence that an intervention is efficacious in reducing or
eliminating the harm by virtue of eliminating the offend-
ing cause or disrupting a harmful chain of events. In
addition, events to be included in assessment for pre-
ventability ought to have clear and validated criteria for
harm level. As we have seen, the available definitions
offer elements of the first one or two of these criteria
with many affected by hindsight bias (violation of the
second criterion). Few push their definitions to require
empirical evidence of preventability.
Given the low level of confidence the data afford
regarding measures of preventability, perhaps it would
be prudent to add a modifier that would reflect the ex-
tent of adherence to these standards, such as definite,
probable, and plausible. Definitely preventable harms,
for instance, will apply to wrong treatment situations or
Page 7 of 8
error-prone complex processes with empirical evidence
from a randomized trial that an intervention (e.g., check-
list) consistently reduces the risk of harm by a large ex-
tent. Definitely preventable harms are ready to become
targets for improvement and accountability. Probably
and plausibly, preventable harms may require additional
empirical work to become targets for improvement and
accountability. As we discussed above, as the evidence
evolves (new technologies appear, new evidence support-
ing these technologies emerges), harms which may have
been plausibly preventable or not preventable may be-
come definitely preventable. This classification therefore
allows the safety community to work not only to reduce
harm and improve safety but also to enhance the quality
of the science of healthcare delivery. Future primary re-
search in this area is needed to advance the field. Rando-
mized or quasi randomized trials (e.g., pre-post design,
comparative controlled cohort studies) will be needed to
test the effectiveness of interventions that target harm
associated with the delivery of healthcare. These trials
will help determine a possible ceiling for improvement
and define what is preventable. We believe that estab-
lishing a definition of preventable harm is desirable and
may help guide quality improvement efforts and safety
initiatives; however, a proposed definition would need to
be sufficiently nuanced to reflect the setting and purpose
of the preventability designation.
Limitations
This systematic review has several limitations that are
worth acknowledging. Judgments made by reviewers of
the literature, despite the good inter-reviewer agreement,
remain subjective. The definitions are clearly correlated
and do not represent independent constructs. We fo-
cused our literature search on the last decade aiming at
identifying a contemporary view; however, prior litera-
ture may provide relevant data. We searched using text-
words in English which also may have led to omitting
additional relevant information. The analysis in this sys-
tematic review was meta-narrative, i.e., non-quantitative;
hence, providing more specific estimates for the oper-
ational characteristics of definitions was not feasible.
Lastly, this review is focused on preventability and not
ameliorability. Others have distinguished between pre-
ventable adverse drug reactions (caused by an error in
management) and ameliorable (their severity could have
been significantly reduced if health care delivery had
been optimal) [18]. The ameliorability concept is not ap-
plicable to all harms (e.g., mortality) and the current sys-
tematic review does not address its definitions.
Conclusions
There is limited empirical evidence of the validity and
reliability of the available definitions of preventable
Nabhan et al. BMC Health Services Research 2012, 12:128
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harm, such that no single one is supported by high qual-
ity evidence. The most common definition is “presence
of an identifiable, modifiable cause of harm”.
Additional files
Additional file 1: Actual search strategy.
Additional file 2: Table S1. Characteristics of included publications.
Additional file 3: Table S2. Number of articles reported under each
definition, broken up by the type of harm.
Competing interests
The authors declare that they have no competing interests.
Acknowledgments
This study was funded by the Center for the Science of Health Care Delivery,
Mayo Clinic, Rochester, MN. The corresponding author had full access to all
of the data in the study and takes responsibility for the integrity of the data
and the accuracy of the data analysis.
Author details
1
Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN,
USA. 2Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN,
USA. 3Division of Anesthesiology and Critical Care, Mayo Clinic, Rochester,
MN, USA. 4Division of Heath Care Policy Research, Mayo Clinic, Rochester,
MN, USA. 5Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo
Clinic, Rochester, MN, USA. 6Mayo Clinic Libraries, Mayo Clinic, Rochester, MN,
USA. 7Department of Radiology, Mayo Clinic, Rochester, MN, USA. 8Division
of Infectious Diseases, Mayo Clinic, Rochester, MN, USA. 9Division of
Preventive Medicine, Mayo Clinic College of Medicine, 200 First Street SW,
Rochester, MN 55905, USA.
Disclaimer
This systematic review adheres to the PRISMA guidelines.
Authors’ contributions
MHM, MN, and VL designed the study. LP performed the search strategy and
retrieved the data. MN, TBE, and MHM reviewed the articles and determined
eligibility for inclusion, and drafted the manuscript. TM, JD, JN, AL, SS, VR, RT,
and RT made substantial contributions to the analysis and interpretation of
data, as well as, drafting of the manuscript. All authors approved the final
manuscript.
Received: 15 November 2011 Accepted: 25 May 2012
Published: 25 May 2012
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doi:10.1186/1472-6963-12-128
Cite this article as: Nabhan et al.: What is preventable harm in
healthcare? A systematic review of definitions. BMC Health Services
Research 2012 12:128.
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